MCCC Walk Application

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Please fill out completely and accurately.

Name (First and Last) *

Please use the name the pilgrim goes by - this will be the name that goes on the nametag and all the other personalized items. It is critical that it is right and the one the pilgrim uses. We DO NOT need the pilgrim's formal, legal name.

Mailing Address *

Please enter the pilgrim's mailing address.

City, State and Zip *

Please enter the pilgrim's city, state, and zip code.

Phone

Please enter the pilgrim's primary phone number, including area code (please use xxx xxx-xxxx format)

Other Phone

Enter a second phone number if there is another the pilgrim uses.

Email Address *

This is BY FAR the best way to contact and get information to pilgrims, so PLEASE enter it if he/she has one. If not, please enter "None." Please be sure it is accurate!

Date of Birth *

Please enter the pilgrim's date of birth (use MM/DD/YYYY format). We use this information for several things, so it is very important!

Gender *

Male

Female

Required

Clergy?

Please check Yes if the pilgrim is a member of the clergy.

Yes

Occupation *

Please enter the pilgrim's primary occupation.

Shirt Size *

Other:

Required

Smoking Preference *

Yes

Required

Marital Status *

Married (enter name below if you check this box)

Single

Divorced

Widowed

Separated

Engaged

Required

Spouse Name

Please enter name of spouse if pilgrim is married.

Church *

Please enter the name of the church the pilgrim attends. Use None if not actively attending anywhere at this time.

Special Needs

Please enter any need for physical assistance, dietary accommodations, or medicines that pilgrim will need to be reminded about.

Emergency Contact Name *

Please enter the name and phone number of an emergency contact. Please DO NOT list the sponsor here. We already have the sponsor's info. We need another contact in case we can't reach the sponsor in the event of an emergency. Pilgrim's spouse would be the logical choice, if married.

Emergency Contact Phone Number *

Relationship of Emergency Contact to Pilgrim *

Spouse

Parent

Child

Sibling

Friend

Other:

Required

Sponsor *

Please enter the name of the sponsor here. This is the person that will receive sponsor confirmation and information.

Sponsor Status *

Please indicate if sponsor is already in our database or needs to be added. Be sure to include contact info (including date of birth and shirt size) if you are a new sponsor.

Member of Mesquite Country Christian Community

New sponsor to be added to database

Other:

Required

Sponsor Contact Info *

Please enter contact info for sponsor (address, phone, email), especially if it needs to be updated or added to our database. If you are entering multiple applications, you do not have to do this on every one - you may put "On file" or something like that.

Payment *

Please indicate how you are going to pay, and then do it!

Full payment using Paypal ($180)

Mail full payment via check/money order ($175)

Will deliver personally ($175)

Applying for scholarship, will pay half ($90) using Paypal

Applying for scholarship, will pay half ($88) via check/money order

WILD Church member

Christian Temple member

Other:

Required

Comments

Please indicate anything else we need to know. For example, are there friends or family members attending that we need to be aware of when assigning rooms and tables?

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